7 Lung Cancer Nursing Care Plans

Impaired Gas Exchange

Centrally located obstructing tumors can cause the collapse of the entire lung with an absence of breath sounds on the side of the lesion. Rapid tumor growth may lead to obstruction of major airways, with distal collapse leading to post-obstructive pneumonia, infection, and fever (Tan & Karim, 2021).

Nursing Diagnosis

• Impaired Gas Exchange

May be related to

• Removal of lung tissue
• Altered oxygen supply (hypoventilation)
• Decreased oxygen-carrying capacity of blood (blood loss)

Possibly evidenced by

• Dyspnea
• Restlessness/changes in mentation
• Hypoxemia and hypercapnia
• Cyanosis

Desired Outcomes

• The client will demonstrate improved ventilation and adequate oxygenation of tissues by ABGs within the normal range.
• The client will be free of symptoms of respiratory distress.

Nursing Assessment and Rationales

1. Note respiratory rate, depth, and ease of respiration. Note the use of accessory muscles and pursed-lip breathing. 
Respirations may be increased as a result of pain or as an initial compensatory mechanism to accommodate for the loss of lung tissue. Additionally, respiratory insufficiency is signaled by dyspnea and increased work of breathing, retractions, orthopnea, and cyanosis. In SCLC, clients usually experience shortness of breath; physical examination may reveal the use of the accessory muscles of respiration and nasal flaring (Tan & Karim, 2021).

2. Observe changes in skin or mucous membrane color, pallor, cyanosis, and edema.
Increased work of breathing and cyanosis may indicate increasing oxygen consumption, energy expenditures, and reduced respiratory reserve. Examination of the extremities may reveal clubbing, cyanosis, or edema. In the presence of superior vena cava (SVC) obstruction, the right upper extremity is usually edematous (Tan & Karim, 2021).

3. Auscultate lungs for air movement and abnormal breath sounds.
Consolidation and lack of air movement on the operative side are normal in the pneumonectomy client; however, the lobectomy client should demonstrate normal airflow in the remaining lobes. In clients diagnosed with NSCLC, upper airway obstruction is manifested by stridor and wheezing. Lower airway obstruction is manifested by asymmetric breath sounds, pleural effusion, pneumothorax, infiltrates, and post-obstructive processes (Tan & Karim, 2022).

4. Investigate restlessness and changes in mentation or level of consciousness.
A neurologic examination should be performed to assess for focal neurological deficits caused by brain metastases and for signs of spinal cord compression (Tan & Karim, 2022). This may also indicate increased hypoxia or complications such as a mediastinal shift in the pneumonectomy client when accompanied by tachypnea, tachycardia, and tracheal deviation.

5. Assess the client’s response to the activity. 
Increased oxygen consumption demand and stress of surgery can result in increased dyspnea and changes in vital signs with activity; however, early mobilization is desired to help prevent pulmonary complications and to obtain and maintain respiratory and circulatory efficiency. 

6. Note the development of fever.
Fever within the first 24 hours after surgery is frequently due to atelectasis. Temperature elevation within the 5th to 10th postoperative day usually indicates a wound or systemic infection.

7. Assess for cough and mucus production, hemoptysis, and chest pain.
Cough is present in 50 to 75% of clients diagnosed with lung cancer. Cough productive of large volumes of thin, mucoid secretions is seen in mucinous adenocarcinoma. In some cases, especially those with exophytic bronchial masses, a cough may signify secondary post-obstructive pneumonia. Hemoptysis is present in 15 to 30% of clients with lung cancer. Chest pain is present in approximately 20 to 40% of clients (Munakomi, 2022).

8. Monitor and graph ABGs, and pulse oximetry readings. Note hemoglobin (Hb) levels.
Decreasing Pao₂ or increasing Paco₂ may indicate the need for ventilatory support. Significant blood loss can result in decreased oxygen-carrying capacity, reducing Pao₂. Arterial blood gas (ABG) levels are useful in the detection of respiratory failure in sick clients. Obtain ABG levels in clients with active systemic diseases or abnormal labored breathing (Tan & Karim, 2022).

9. Monitor chest radiography results and other imaging tests as indicated.
A chest radiograph is usually the first test ordered in clients in whom a lung malignancy is suggested. Clues from the chest radiograph may suggest the diagnosis of lung cancer, but may not be helpful in identifying a histologic subtype. A chest CT scan is a standard for lung cancer staging. The findings of CT scans of the chest and clinical presentation usually allow a presumptive differentiation between NSCLC and SCLC (Tan & Karim, 2022).

Nursing Interventions and Rationales

1. Encourage rest periods and limit activities according to client tolerance.
Adequate rest balanced with activity can prevent respiratory compromise. The client’s activity level, as measured by a performance status scale is an important prognostic factor. The client should be encouraged to remain active during and after treatment for lung cancer (Tan & Karim, 2022).

2. Educate regarding smoking cessation.
Advise clients that smoking cessation is the most important measure for preventing lung cancer; it may also improve prognosis in clients with early-stage lung cancer. Smoking cessation by others who share the client’s home, car, or both is also important. According to published data, the use of nicotine alternatives instead of cigarettes reduces the incidence of lung cancer, although it does not affect the incidence of ischemic heart disease (Tan & Karim, 2022).

3. Maintain patent airway by positioning, suctioning, and use of airway adjuncts.
Airway obstruction impedes ventilation, impairing gas exchange. In the case of upper airway obstruction, the client is admitted to the ICU, and prepared for intubation and/or cricothyrotomy and intraoperative tracheostomy (Tan & Karim, 2022).

4. Reposition frequently, placing the client in sitting positions and supine to side positions. However, avoid positioning the client with a pneumonectomy on the operative side; instead, favor the “good lung down” position.
This maximizes lung expansion and drainage of secretions. Research shows that positioning clients following lung surgery with their “good lung down” maximizes oxygenation by using gravity to enhance blood flow to the healthy lung, thus creating the best possible match between ventilation and perfusion (Lan et al., 2011).

5. Encourage and assist with deep-breathing exercises and pursed-lip breathing as appropriate.
This promotes maximal ventilation and oxygenation and reduces or prevents atelectasis. Breathing exercises aim to correct breathing errors, reestablish proper breathing patterns, increase diaphragm activity, elevate the amount of alveolar ventilation, reduce energy consumption when breathing, and relieve the shortness of breath experienced by clients diagnosed with lung cancer (Liu et al., 2013).

6. Maintain patency of the chest drainage system for lobectomy, segmental, or wedge resection.
These drain fluid from the pleural cavity to promote the re-expansion of remaining lung segments. The balanced chest drainage system was found to be associated with reduced rates of post-pneumonectomy pulmonary edema, which is a common cause of death after pneumonectomy (Wei Lo et al., 2020).

7. Note changes in the amount or type of chest tube drainage.
Bloody drainage should decrease in amount and change to a more serous composition as recovery progresses. A sudden increase in the amount of bloody drainage or return to frank bleeding suggests thoracic bleeding or hemothorax; sudden cessation suggests blockage of the tube, requiring further evaluation and intervention.

8. Observe the presence or degree of bubbling in the water-seal chamber.
Air leaks immediately postoperative are not uncommon, especially following lobectomy or segmental resection; however, this should diminish as healing progresses. Most intrathoracic air leaks will usually seal spontaneously, and resolution can be tracked by witnessing decreased bubbling in the device over days. Prolonged or new leaks require evaluation to identify problems in clients versus the drainage system (Merkle & Cindass, 2022).

9. Administer supplemental oxygen via nasal cannula, partial rebreathing mask, or high-humidity face mask, as indicated.
This maximizes available oxygen, especially while ventilation is reduced because of anesthetic, depression, or pain, and during the period of the compensatory physiological shift of circulation to remaining functional alveolar units. If hemoptysis is noted, administer supplemental oxygen and perform suctioning. If a threat of imminent demise exists, consider placing a double-lumen endotracheal tube (Tan & Karim, 2022).

10. Assist with and encourage the use of incentive spirometer.
This prevents or reduces atelectasis and promotes the re-expansion of small airways. Lung expansion therapy allows the client to maintain an effective cough mechanism to facilitate the removal of secretions from the airways following surgery. An incentive spirometer is a medical device, which helps the client sustain maximal inspiration under visual quantitation by inspiratory effort (Liu et al., 2019).